Training to Meet Demand
As demand for injectables increases, programs need more health care workers who can provide injectables. Staffing decisions and training content depend on a program's specific needs. An assessment in advance can help to determine who most needs training and in what (110, 136).
Method Introduction or New Providers May Require Comprehensive Training
Comprehensive training to provide injectables may be needed if a program is adding injectables as a new method or if a program already offers injectables but is training new health care workers to provide them. Depending on providers' skill levels and on program needs, comprehensive training on injectables may include:
- Characteristics of injectable contraceptives and the importance of returning on time for the next injection,
- Giving injections using the universal precautions (see Give Injections and Dispose of Waste Safely),
- Counseling clients, with emphasis on bleeding changes,
- Screening clients using the Medical Eligibility Criteria (see the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) in the companion issue of INFO Reports),
- Counteracting myths and correcting misperceptions,
- Conducting return visits and ensuring continuity of care (see forthcoming Population Reports, "Developing a Continuing Client Strategy"), and
- Managing side effects.
The time needed for training depends on the amount of content, the initial skill level of trainees, program needs, and policy requirements. The Pathfinder International DMPA Training Module (see Table 3) covers characteristics of DMPA, counseling, giving the injection, conducting return visits, and managing side effects. The module is designed for trainees to practice and demonstrate competence in each skill. It requires about 16 hours to complete (181). In contrast, in a pilot community distribution program in Uganda (see Community Programs Can Safely Increase Access to Injectables), community providers who had been providing oral contraceptives and condoms received comprehensive injectables training that included one week of classroom sessions and two weeks in hospitals and health centers (123, 183).
Focused Training Meets Specific Needs
To meet demand quickly, programs may consider training current staff members, such as assistant or auxiliary workers, to give only routine repeat injections. This would free doctors and nurses to handle special needs (see With Training, a Range of Providers Can Give Contraceptive Injections). A short training course for providing repeat injections might focus on the first three topics listed in Method Introduction or New Providers May Require Comprehensive Training: characteristics of injectables, giving safe injections, and counseling.
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Any health care provider who is appropriately trained can give injections safely.
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Focused training also can be used to address a specific component of service delivery that needs strengthening, such as counseling. For example, when Vietnam was scaling up the provision of DMPA in 1999, an assessment of an earlier pilot project found that client visits typically involved little counseling and that providers and program managers believed that a woman's choice about contraceptives was best made by the provider. As a result of this finding, providers received focused training in providing balanced information, listening to clients' concerns, and offering individually tailored guidance. This training improved counseling and helped women make an informed choice of DMPA and other contraceptives (224).
Refresher training maintains skills. Regular retraining can help maintain safe injection practices and maintain good quality of care generally (218). For example, in a 2005 survey of 526 nurses and midwives in Uganda, the reported frequency of needlestick injuries was lower among those who had attended safe injection training in their workplace than among those who had not had workplace training (129).
Depending on program needs, refresher training may be offered one or two times per year (74). Retraining also may address clinic staff other than providers, such as waste handlers (93).
Competency-Based Training Works Best
Training that develops the skills, knowledge, and attitudes required to meet standards—known as competency-based training—has proved more effective than conventional training approaches, in which trainees may have little opportunity to practice skills (185). With this approach, training continues until each trainee is competent to provide injectables. The training uses techniques such as role playing, discussion, use of job aids, and simulation (93). Vietnam used the competency-based approach to training when scaling up DMPA services in 1999 (224).
Supportive Supervision Can Encourage Good-Quality Services
Supportive supervisors are those who meet the needs of the staff they supervise, thus enabling providers to perform well and meet the needs of their clients (47). By giving constructive performance feedback, supportive supervisors can help staff correctly follow injection guidelines, improve their performance, identify operational barriers, and maintain standards (189). Ongoing supportive supervision is particularly important when programs increase the number of providers giving injections.
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Ongoing supportive supervision is particularly important when programs increase the number of providers giving injections.
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Program managers and providers together can use the Standards-Based Management and Recognition (SBM-R) approach to help improve performance and the quality of services (24, 125) (see Table 3). In this approach supervisors and staff work together to define standards for service and performance, and they determine how to meet those standards. For example, if a supervisor sees that injection safety practices need improvement, SBM-R can guide the supervisor and provider in (1) setting performance standards for safe injections that detail what to do and how to do it; (2) identifying steps needed to meet the standards (such as refresher training in safe injection practices or acquiring more equipment and supplies); (3) measuring progress; and (4) motivating the providers to achieve objectives by offering incentives and recognizing achievements. Supervisors can use the "Checklist for Giving Intramuscular Contraceptive Injections" to ensure that providers are following the appropriate steps (see the companion issue of INFO Reports, "Injectable Contraceptives: Tools for Providers").
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See Companion INFO Reports on "Injectable Contraceptives: Tools for Providers"
